Collect relevant clinical data to support the care planning process Care Plan support, intervention, and prioritization to transition members to optimal levels of health and self management Participate in interdisciplinary team meetings as required Collaboration across providers and healthcare settings to ensure optimal quality outcomes for an assigned population Provide

Conduct clinical audits to ensure alignment with clinical standards; reporting and escalating potential risk exposure and researching quality concerns. Collects and analyzes data from Care Partners to assess outcome and operational metrics; to include facilitating external communication necessary to obtain required information related clinical performance. Prepares and co

Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi cal criteria, Interqual, Milliman, or Health Plan specific guidelines Collaborate with the Medical Director to ensure the